Ophthalmology and Optometry Coding Alert

Question: My ophthalmologist occasionally sees patients, and instead of coming to a conclusive diagnosis, he documents that he is ruling out certain conditions. Is it OK for me to report those conditions as the diagnosis for the encounter?

California Subscriber

Answer: ICD-9 coding guidelines clearly state that you should not report "rule out" diagnoses in the outpatient setting. Instead, you should report the patient's signs and symptoms. You'll avoid labeling the patient with an uncon-firmed diagnosis, and by coding the presenting signs and symptoms, your ophthalmologist will still get paid for his services, even if he cannot establish a definitive diagnosis.

Tip: "Rule out," "suspected," "probable" or "questionable" are words you may see in a patient's chart. You shouldn't report a diagnosis qualified by one of these terms. If there is no definitive diagnosis given, look for any signs or symptoms that the patient presented with.

Example: The ophthalmologist sees an elderly patient who complains of pain and decreased vision in her right eye, and the physician suspects that the woman may have nerve damage from a foreign body he removed the week before.

Correct coding in this instance depends on available documentation. If the ophthalmologist notes that he is attempting to "rule out" the nerve damage, you should report the signs and symptoms (e.g., 379.91, Unspecified disorder of eye and adnexa; pain in or around eye, for the generalized eye pain; or 369.9, Decreased vision).

Remember: CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnosis. Instead, "code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results ...," the guidelines state.

Good practice: Talk to your ophthalmologists about how important accurate terms are. Tell the physician that if he can come to a definite conclusion about the patient's diagnosis, he needs to state this in his dictation so you may choose the best code. The ophthalmologist's documenting the "rule out" or "possible" problems in his documentation to support the reason for ordering diagnostic tests and support medical necessity is certainly appropriate, however.